Catastrophic health expenditures, insurance churn, and nonemployment among gynecologic cancer patients in the United States.

BACKGROUND: In recent years, there has been growing recognition of the financial burden of severe illness, including associations with higher rates of nonemployment, uninsurance, and catastrophic out-of-pocket health spending. Patients with gynecologic cancer often require expensive and prolonged treatments, potentially disrupting employment and insurance coverage access, and putting patients and their families at risk for catastrophic health expenditures. OBJECTIVE: This study aimed to describe the prevalence of insurance churn, nonemployment, and catastrophic health expenditures among nonelderly patients with gynecologic cancer in the United States, to compare within subgroups and to other populations and assess for changes associated with the Affordable Care Act. STUDY DESIGN: We identified respondents aged 18 to 64 years from the Medical Expenditure Panel Survey, 2006 to 2017, who reported care related to gynecologic cancer in a given year, and a propensity-matched cohort of patients without cancer and patients with cancers of other sites, as comparison groups. We applied survey weights to extrapolate to the US population, and we described patterns of insurance churn (any uninsurance or insurance loss or change), catastrophic health expenditures (>10% annual family income), and nonemployment. Characteristics and outcomes between groups were compared with the adjusted Wald test. RESULTS: We identified 683 respondents reporting care related to a gynecologic cancer diagnosis from 2006 to 2017, representing an estimated annual population of 532,400 patients (95% confidence interval, 462,000-502,700). More than 64% of patients reported at least 1 of 3 primary negative outcomes of any uninsurance, part-year nonemployment, and catastrophic health expenditures, with 22.4% reporting at least 2 of 3 outcomes. Catastrophic health spending was uncommon without nonemployment or uninsurance reported during that year (1.2% of the population). Compared with patients with other cancers, patients with gynecologic cancer were younger and more likely with low education and low family income (≤250% federal poverty level). They reported higher annual risks of insurance loss (8.8% vs 4.8%; P=.03), any uninsurance (22.6% vs 14.0%; P=.002), and part-year nonemployment (55.3% vs 44.6%; P=.005) but similar risks of catastrophic spending (12.6% vs 12.2%; P=.84). Patients with gynecologic cancer from low-income families faced a higher risk of catastrophic expenditures than those of higher icomes (24.4% vs 2.9%; P<.001). Among the patients from low-income families, Medicaid coverage was associated with a lower risk of catastrophic spending than private insurance. After the Affordable Care Act implementation, we observed reductions in the risk of uninsurance, but there was no significant change in the risk of catastrophic spending among patients with gynecologic cancer. CONCLUSION: Patients with gynecologic cancer faced high risks of uninsurance, nonemployment, and catastrophic health expenditures, particularly among patients from low-income families. Catastrophic spending was uncommon in the absence of either nonemployment or uninsurance in a given year.

The impact of the Patient Protection and Affordable Care Act on insurance coverage and cancer-directed treatment in HIV-infected patients with cancer in the United States.

BACKGROUND: To the authors' knowledge, little is known regarding the impact of the Patient Protection and Affordable Care Act (ACA) on people living with HIV and cancer (PLWHC), who have lower cancer treatment rates and worse cancer outcomes. To investigate this research gap, the authors examined the effects of the ACA on insurance coverage and receipt of cancer treatment among PLWHC in the United States. METHODS: HIV-infected individuals aged 18 to 64 years old with cancer diagnosed between 2011 and 2015 were identified in the National Cancer Data Base. Health insurance coverage and cancer treatment receipt were compared before and after implementation of the ACA in non-Medicaid expansion and Medicaid expansion states using difference-in-differences analysis. RESULTS: Of the 4794 PLWHC analyzed, approximately 49% resided in nonexpansion states and were more often uninsured (16.7% vs 4.2%), nonwhite (65.2% vs 60.2%), and of low income (36.3% vs 26.9%) compared with those in Medicaid expansion states. After 2014, the percentage of uninsured individuals decreased in expansion states (from 4.9% to 3%; P = .01) and nonexpansion states (from 17.6% to 14.6%; P = .06), possibly due to increased Medicaid coverage in expansion states (from 36.9% to 39.2%) and increased private insurance coverage in nonexpansion states (from 29.5% to 34.7%). There was no significant difference in cancer treatment receipt noted between Medicaid expansion and nonexpansion states. However, the percentage of PLWHC treated at academic facilities increased significantly only in expansion states (from 40.2% to 46.7% [P < .0001]; difference-in-differences analysis: 7.2 percentage points [P = .02]). CONCLUSIONS: The implementation of the ACA was associated with improved insurance coverage among PLWHC. Lack of insurance still is common in non-Medicaid expansion states. Patients with minority or low socioeconomic status more often resided in nonexpansion states, thereby highlighting the need for further insurance expansion.

Off-study utilization of experimental therapies: Analysis of GOG249-eligible cohorts using real world data.

OBJECTIVE: Adjuvant management of women with high-intermediate- and high-risk early-stage endometrial cancer remains controversial. Recently published results of GOG 249 revealed that vaginal brachytherapy plus chemotherapy (VBT + CT) was not superior to whole pelvic radiation therapy (WPRT) and was associated with more toxicities and higher nodal recurrences. This study examined off-study utilization of VBT + CT among women who met criteria for GOG 249 in the period prior to study publication. METHODS: Women diagnosed with FIGO IA-IIB endometrioid, serous, or clear cell uterine cancer between 2004-2015 and treated with hysterectomy and radiotherapy (RT) were identified in the National Cancer Database. Cochrane-Armitrage trend test was used to assess trends over time. Univariate and multivariate Cox analyses were performed to calculate odds ratio (OR) of VBT + CT receipt and hazard ratio (HR) of OS. Propensity-score matched analysis was conducted to account for baseline differences. RESULTS: 9956 women met inclusion criteria. 7548 women (75.8%) received WPRT while 2408 (24.2%) received VBT + CT in the study period. From 2004-2015, there was a significant increase in VBT + CT use (p < 0.001) with the largest overall increase occurring in 2009 to 22%. Factors significantly associated with VBT + CT receipt included higher socioeconomic status (p < 0.001), higher grade endometrioid cancer (p < 0.001), and aggressive histology (p < 0.001). After propensity-score matching, VBT + CT was associated with improved OS (HR 0.74, 95% CI 0.58-0.93); however, when stratified by FIGO stage, VBT + CT was only associated with improved OS for FIGO stage 1B (HR 0.62, 95% CI 0.44-0.87). CONCLUSIONS: There was significant use of experimental arm off-study treatment in the United States prior to report of GOG 249 results. Providers should be cautious when offering off-study treatment utilizing an experimental regimen given uncertainty about efficacy and toxicity.

Place of death by region and urbanization among gynecologic cancer patients: 2006-2016.

OBJECTIVE: To evaluate associations between US region of residence and urbanization and the place of death among women with gynecologic malignancies in the United States. METHODS: A retrospective cross-sectional study was performed using publicly available death certificate data from the National Center for Health Statistics. All gynecologic cancer deaths were included from 2006 to 2016. Comparisons among categories were performed with a two-tailed chi-square test, with p-values <0.05 considered significant. RESULTS: From 2006 to 2016, 328,026 women died from gynecologic malignancies in the US. Of these deaths, 40.1% (n = 134,333) occurred in the patient's home, 24.9%(n = 81,823) in the hospital, and 11.3% (37,188) in an inpatient hospice facility. Place of death varied by geographic region. The Northeast had the largest percentage of gynecologic cancer patients (31.3%) die as a hospital inpatient. The West had the highest percentage of deaths (49.3%) at home. Deaths in a hospice facility were the highest (14.1%) in the South. Place of death varied by urbanization; patients residing in large central metro or rural counties were the most likely to die during hospital admission (28.7% and 27.1%, respectively). Patients living in medium-sized metro areas were the least likely to die in hospitals (21.8%) and most likely to die in a hospice facility (14.3%). All comparisons were significant by study definition. CONCLUSION: The place of death for patients with gynecologic malignancies varies by US region and urbanization. These disparities are multifactorial in nature, likely influenced by both sociodemographic factors and regional resource availability. In this study, however, rural and central metro areas are identified as regions that may benefit from further hospice development and advocacy.

Place of death for patients with cancer in the United States, 1999 through 2015: Racial, age, and geographic disparities.

BACKGROUND: Place of death is an essential component of high quality cancer care and comprehensive national trends and disparities in place of death are unknown. METHODS: Deidentified death certificate data were obtained via the National Center for Health Statistics. All cancer deaths from 1999 through 2015 were included. Multivariate logistic regression was used to test for disparities in place of death associated with sociodemographic variables. RESULTS: From 1999 through 2015, a total of 9,646,498 cancer deaths occurred. Hospital deaths decreased (from 36.6% to 24.6%), whereas the rate of home deaths (38.4% to 42.6%) and hospice facility deaths (0% to 14.0%) both increased (all P<.001). On multivariate logistic regression, all assessed variables were found to be associated with place of death. Specifically, younger age (age birth-14 years: odds ratio [OR], 2.39; age 25-44 years: OR, 1.62), black (OR, 1.83) or Asian (OR, 1.74) race, and Hispanic ethnicity (OR, 1.41) were associated with hospital death. Being married (OR, 2.17) or widowed (OR, 1.56) was associated with home death whereas increasing educational level (OR, 1.15-1.19) was associated with hospice death (all P<.001). Despite overall improvements, certain disparities were found to increase. For young patients, the likelihood of a hospital death increased from 2.3 times to 3.4 times that of older patients (50.9% for those aged 15-24 years vs 15.0% for those aged ≥85 years in 2015). For black patients, the likelihood of a hospital death increased from 1.29 times to 1.42 times that of white patients (32.8% for black patients vs 23.1% for white patients in 2015). CONCLUSIONS: Hospital cancer deaths decreased by approximately one-third with commensurate increases in home and hospice facility deaths. Many sociodemographic groups experience significant disparities with regard to place of death and may benefit from targeted efforts to improve goal-concordant care.

Cost Effectiveness of Risk-Reducing Mastectomy versus Surveillance in BRCA Mutation Carriers with a History of Ovarian Cancer.

BACKGROUND: The appropriate management of breast cancer risk in BRCA mutation carriers following ovarian cancer diagnosis remains unclear. We sought to determine the survival benefit and cost effectiveness of risk-reducing mastectomy (RRM) among women with BRCA1/2 mutations following stage II-IV ovarian cancer. DESIGN: We constructed a decision model from a third-party payer perspective to compare annual screening with magnetic resonance imaging (MRI) and mammography to annual screening followed by RRM with reconstruction following ovarian cancer diagnosis. Survival, overall costs, and cost effectiveness were determined by decade at diagnosis using 2015 US dollars. All inputs were obtained from the literature and public databases. Monte Carlo probabilistic sensitivity analysis was performed with a $100,000 willingness-to-pay threshold. RESULTS: The incremental cost-effectiveness ratio (ICER) per year of life saved (YLS) for RRM increased with age and BRCA2 mutation status, with greater survival benefit demonstrated in younger patients with BRCA1 mutations. RRM delayed 5 years in 40-year-old BRCA1 mutation carriers was associated with 5 months of life gained (ICER $72,739/YLS), and in 60-year-old BRCA2 mutation carriers was associated with 0.8 months of life gained (ICER $334,906/YLS). In all scenarios, $/YLS and mastectomies per breast cancer prevented were lowest with RRM performed 5-10 years after ovarian cancer diagnosis. CONCLUSION: For most BRCA1/2 mutation carriers following ovarian cancer diagnosis, RRM performed within 5 years is not cost effective when compared with breast cancer screening. Imaging surveillance should be advocated during the first several years after ovarian cancer diagnosis, after which point the benefits of RRM can be considered based on patient age and BRCA mutation status.

Impact of Chemotherapy and Radiotherapy on Management of Early Stage Clear Cell and Papillary Serous Carcinoma of the Uterus.

OBJECTIVE: The aim of the study was to assess interaction of lymph node dissection (LND), adjuvant chemotherapy (CT), and radiotherapy (RT) in stage I uterine papillary serous carcinoma (UPSC) and uterine clear cell carcinoma (UCC). METHODS/MATERIALS: The National Cancer Data Base was queried for women diagnosed with International Federation of Gynecology and Obstetrics stage I UPSC and UCC from 1998 to 2012. Overall survival (OS) was estimated for combinations of RT and CT by the Kaplan-Meier method stratified by histology and LND. Multivariate Cox proportional hazard models were generated. RESULTS: Uterine papillary serous carcinoma: 5432 women with UPSC were identified. Uterine papillary serous carcinoma had the highest 5-year OS with CT + RT with (83%) or without LND (76%). On multivariate analyses, CT [hazard ratio (HR), 0.77; P = 0.01] and vaginal cuff brachytherapy (HR, 0.68; P = 0.003) with LND were independently associated with OS. Without LND, vaginal cuff brachytherapy (HR, 0.53; P = 0.03), but not CT (HR, 1.21; P = 0.92), was associated with OS. Uterine clear cell carcinoma: 2516 women with UCC were identified. Uterine clear cell carcinoma with and without LND had comparable 5-year OS for all combinations of CT and RT on univariate and multivariate analyses. CONCLUSIONS: In stage I papillary serous uterine cancer, brachytherapy and CT were associated with increased survival; however, the benefit of chemotherapy was limited to those with surgical staging. In contrast, no adjuvant therapy was associated with survival in stage I uterine clear cell carcinoma, and further investigation to identify more effective therapies is warranted.

Smoking history predicts for increased risk of second primary lung cancer: a comprehensive analysis.

BACKGROUND: Tobacco use is the most important risk factor for the development of lung cancer. The objective of the current study was to determine the effect of smoking on the development of second primary lung cancers (SPLCs) and other clinical outcomes after surgery for non-small cell lung cancer (NSCLC). METHODS: All patients who underwent surgery for NSCLC at the study institution from 1995 through 2008 were identified. Rates of SPLC were analyzed based on smoking status and pack-year exposure. Multivariate analysis was performed to determine risk factors for SPLC. Overall survival, local control, distant metastases, and postoperative mortality were also examined. RESULTS: A total of 1484 patients were identified, including 98 never-smokers. The incidence of SPLC at 3 years, 5 years, and 8 years was 5%, 8%, and 16%, respectively. Only 1 never-smoker developed an SPLC. On multivariate analysis, which was restricted to ever-smokers with pack-years as a continuous variable, smoking history was found to be the only independent risk factor for SPLC (hazard ratio, 1.08; 95% confidence interval, 1.02-1.16 [P = .031]), corresponding to an 8% increased risk per 10 pack-year exposure. There were no differences in rates of local control or distant metastases based on smoking status. There was a trend toward lower postoperative mortality in never-smokers compared with ever-smokers (0% vs 3.3%; P = .069). Overall survival was found to be significantly worse for current smokers compared with former and never-smokers. CONCLUSIONS: SPLCs are rare in never-smokers. Increasing tobacco exposure is associated with a higher risk of SPLC in patients with a history of smoking. Current smokers have an increased risk of mortality whereas former and never-smokers have comparable survival.

Gemcitabine-induced radiation recall myositis.

Radiation recall is an uncommon phenomenon in which administration of a chemotherapeutic agent induces an acute inflammatory reaction in previously irradiated tissues, often weeks to years after completion of radiotherapy. This entity is well known to medical and radiation oncologists, however only three cases have been reported in radiology journals. We present a case of gemcitabine-induced radiation recall that manifested as myositis with associated dermatitis in the posterior thigh of a patient with remote history of localized radiotherapy for biopsy-proven breast cancer metastasis. We also present a brief literature review to update the topic of radiation recall in imaging, and emphasize the importance of knowledge of this phenomenon when considering the differential diagnosis of myositis/dermatitis in a patient who has received cancer treatment.

Combinatorial Approaches for Chemotherapies and Targeted Therapies With Radiation: United Efforts to Innovate in Patient Care.

Combinatorial therapies consisting of radiation therapy (RT) with systemic therapies, particularly chemotherapy and targeted therapies, have moved the needle to augment disease control across nearly all disease sites for locally advanced disease. Evaluating these important combinations to incorporate more potent therapies with RT will aid our understanding of toxicity and efficacy for patients. This article discusses multiple disease sites and includes a compilation of contributions from expert Red Journal editors from each disease site. Leveraging improved systemic control with novel agents, we must continue efforts to study novel treatment combinations with RT.

How much is another randomized trial of lymph node dissection in endometrial cancer worth? A value of information analysis.

OBJECTIVE: This study aimed to assess the value of a randomized controlled trial (RCT) of lymph node dissection (LND) at the time of hysterectomy for high-risk subsets of women with endometrial cancer. METHODS: A modified Markov decision model compared routine LND to no LND for women with grade 3 or grades 2-3 endometrial cancer. Inputs were modeled as distributions for Monte Carlo probabilistic sensitivity and value of information (VOI) analyses. Survival without LND was modeled from Surveillance, Epidemiology and End Results program data. A hazard ratio (HR) describing survival in the high-risk group undergoing LND (estimate 0.9, 95% CI 0.6-1.1), adverse event rates, probability and type of adjuvant therapy were modeled from published RCTs. Costs were obtained from national reimbursement data. VOI estimated the value of reducing uncertainty regarding the survival benefit of LND. RESULTS: For grade 3, LND had an incremental cost-effectiveness ratio of $40,183/quality-adjusted life year (QALY) compared to no LND. Acceptability curves revealed considerable uncertainty, with an expected value of perfect information of $4,195 per patient at societal willingness to pay of $50,000/QALY. The estimated value of partial perfect information regarding the HR was $3,702 per patient. Assuming 8,000 individuals annually with grade 3 endometrial cancer in the US, the upper limit of VOI for the HR was $29.6 million annually. For grades 2 and 3 combined, analysis revealed a much lower likelihood of finding LND cost-effective. CONCLUSION: A clinical trial defining the survival effect of LND in women with grade 3 endometrial cancer is a worthwhile use of resources.

What is appropriate target delineation for MRI-based brachytherapy for medically inoperable endometrial cancer?

PURPOSE: For medically inoperable endometrial cancer (MIEC), the volumetric target of image-guided brachytherapy (IGBT) techniques is not well established. We propose a high-risk CTV (HRCTV) concept and report associated rates of local control and toxicity. METHODS AND MATERIALS: For all MIEC patients receiving definitive external beam radiotherapy (EBRT) followed by MRI-based IGBT at a single institution, BT dose was prescribed to HRCTV defined as GTV plus endometrial cavity with a planning goal of a summed EQD2 D90 of ≥85 Gy. Freedom from local progression (FFLP) and overall survival (OS) were estimated via Kaplan Meier method. RESULTS: Thirty two MIEC patients received EBRT followed by MRI-based IGBT between December 2015 and August 2020. Median follow up was 19.8 months. A total of 75% of patients had FIGO stage I/II disease, 56% endometrioid histology, and 50% grade 3 disease. OS was 73.6% (95% CI 57.8%-89.3%) at 12 months and 65.8% (95% CI 48.4%-83.2%) at 24 months. FFLP was 93.8% (95% CI 85.3%-100%) at 12 months and 88.8% (95% CI 86.6%-91.0%) at 24 months. 23 (72%) patients experienced no RT-related toxicity, while 2 of 32 patients (6%) experienced late grade 3+ toxicities (grade 3 refractory vomiting; grade 5 GI bleed secondary to RT-induced proctitis). CONCLUSIONS: Patients with MIEC receiving definitive EBRT followed by MRI-based IGBT prescribed to the MRI-defined HRCTV demonstrated favorable long-term local control with an acceptable toxicity profile.

Insurance Coverage and Forgoing Medical Appointments Because of Cost Among Cancer Survivors After 2016.

PURPOSE: The uninsured rate began rising after 2016, which some have attributed to health policies undermining aspects of the Affordable Care Act. Our primary objectives were to assess the changes in insurance coverage and forgoing medical care because of cost in cancer survivors from pre-enactment (2016) through postenactment of those policies (2019) and determine whether there were subgroups that were disproportionately affected. METHODS: The 2016-2019 Behavioral Risk Factor Surveillance System surveys were queried for 18- to 64-year-old cancer survivors. Survey-weighted logistic regression was used to assess temporal changes in (1) insurance coverage and (2) forgoing medical appointments because of cost in the preceding 12 months. RESULTS: A total of 62,669 cancer survivors were identified. The percentage of insured cancer survivors decreased from 92.4% in 2016 to 90.4% in 2019 (odds ratio for change in insurance coverage or affordability per one-year increase [ORyear], 0.92; 95% CI, 0.86 to 0.98; P = .01), translating to 161,000 fewer cancer survivors in the United States with insurance coverage. There were decreases in employer-sponsored insurance coverage (ORyear, 0.89) but increases in Medicaid coverage (ORyear, 1.17) from 2016 to 2019. Forgoing medical appointments because of cost increased from 17.9% in 2016 to 20.0% in 2019 (ORyear, 1.05; 95% CI, 1.01 to 1.1; P = .025), affecting an estimated 169,000 cancer survivors. The greatest changes were observed among individuals with low income, particularly those residing in nonexpansion states. CONCLUSION: Between 2016 and 2019, there were 161,000 fewer cancer survivors in the United States with insurance coverage, and 169,000 forwent medical care because of cost.

The Affordable Care Act and suicide incidence among adults with cancer.

BACKGROUND: Patients with cancer are at an increased suicide risk, and socioeconomic deprivation may further exacerbate that risk. The Affordable Care Act (ACA) expanded insurance coverage options for low-income individuals and mandated coverage of mental health care. Our objective was to quantify associations of the ACA with suicide incidence among patients with cancer. METHODS: We identified US patients with cancer aged 18-74 years diagnosed with cancer from 2011 to 2016 from the Surveillance, Epidemiology, and End Results database. The primary outcome was the 1-year incidence of suicide based on cumulative incidence analyses. Difference-in-differences (DID) analyses compared changes in suicide incidence from 2011-2013 (pre-ACA) to 2014-2016 (post-ACA) in Medicaid expansion relative to non-expansion states. We conducted falsification tests with 65-74-year-old patients with cancer, who are Medicare-eligible and not expected to benefit from ACA provisions. RESULTS: We identified 1,263,717 patients with cancer, 812 of whom died by suicide. In DID analyses, there was no change in suicide incidence after 2014 in Medicaid expansion vs. non-expansion states for nonelderly (18-64 years) patients with cancer (p = .41), but there was a decrease in suicide incidence among young adults (18-39 years) (- 64.36 per 100,000, 95% CI = - 125.96 to - 2.76, p = .041). There were no ACA-associated changes in suicide incidence among 65-74-year-old patients with cancer. CONCLUSIONS: We found an ACA-associated decrease in the incidence of suicide for some nonelderly patients with cancer, particularly young adults in Medicaid expansion vs. non-expansion states. Expanding access to health care may decrease the risk of suicide among cancer survivors.

Adjuvant radiotherapy in the treatment of invasive intraductal papillary mucinous neoplasm of the pancreas: an analysis of the surveillance, epidemiology, and end results registry.

BACKGROUND: Management and outcomes of patients with invasive intraductal papillary mucinous neoplasm (IPMN) of the pancreas are not well established. We investigated whether adjuvant radiotherapy (RT) improved cancer-specific survival (CSS) and overall survival (OS) among patients undergoing surgical resection for invasive IPMN. METHODS: The Surveillance, Epidemiology, and End Results (SEER) registry was used in this retrospective cohort study. All adult patients with resection of invasive IPMN from 1988 to 2007 were included. CSS and OS were analyzed using Kaplan-Meier curves. Unadjusted and propensity-score-adjusted Cox proportional-hazards modeling were used for subgroup analyses. RESULTS: 972 patients were included. Adjuvant RT was administered to 31.8% (n=309) of patients. There was no difference in overall median CSS or OS in patients who received adjuvant RT (5-year CSS: 26.5 months; 5-year OS: 23.5 months) versus those who did not (CSS: 28.5 months, P=0.17; OS: 23.5 months, P=0.23). Univariate predictors of survival were lymph node (LN) involvement, T4-classified tumors, and poorly differentiated tumor grade (all P<0.05). In the propensity-score-adjusted analysis, adjuvant RT was associated with improved 5-year CSS [hazard ratio (HR): 0.67, P=0.004] and 5-year OS (HR: 0.73, P=0.014) among all patients with LN involvement, though further analysis by T-classification demonstrated no survival differences among patients with T1/T2 disease; patients with T3/T4-classified tumors had improved CSS (HR: 0.71, P=0.022) but no difference in OS (HR: 0.76, P=0.06). CONCLUSION: On propensity-score-adjusted analysis, adjuvant RT was associated with improved survival in selected subsets of patients with invasive IPMN, particularly those with T3/T4 tumors and LN involvement.

Cost effectiveness of concurrent gemcitabine and cisplatin with radiation followed by adjuvant gemcitabine and cisplatin in patients with stages IIB to IVA carcinoma of the cervix.

OBJECTIVE: A recent phase III trial reported gemcitabine with cisplatin chemoradiation followed by 2 cycles of gemcitabine and cisplatin (G) significantly improved progression-free (PFS) and overall survival (OS) compared to standard cisplatin chemoradiation (C) for locally advanced cervix cancer. We evaluate the cost effectiveness (CE) of these treatment regimens. METHODS: A modified Markov model was constructed comparing CE between treatment arms using the published trial's five-year OS and treatment-related toxicity rates. Quality of life (QOL) utility scores during treatment were obtained from published literature and modeled for sensitivity analysis. Cost data was obtained from Medicare reimbursement figures and the Healthcare Cost and Utilization Project. One-way sensitivity analyses assessed variations in cost and adverse events. RESULTS: Mean cost was $41,330 (US$) for C versus $60,974 for G. Incremental cost-effectiveness ratio (ICER) for G compared to C was $33,080 per quality-adjusted life year (QALY). In sensitivity analyses (SA), the ICER increased to common willingness-to-pay thresholds of 50 K and 100 K when QOL utility scores during G active treatment declined to 0.64 and 0.53 (baseline 0.76), respectively. The model was insensitive to changes in adverse event rates, costs of treatment, or adverse event hospitalization costs. CONCLUSIONS: Gemcitabine with cisplatin chemoradiation followed by 2 cycles of adjuvant gemcitabine and cisplatin is a cost effective treatment for locally advanced cervix cancer compared to standard cisplatin chemoradiation. Common willingness to pay thresholds are exceeded during sensitivity analyses with realistic declines in QOL. Our results support ongoing investigations of novel adjuvants to standard cisplatin chemoradiation with potentially less toxicity.